EVALUATION OF ABDOMINAL PAIN IN THE ELDERLY
Section snippets
OVERVIEW
Abdominal pain is estimated to account for 5% to 10% of all ED visits. Faruqi and associates24 in England reported a dramatic increase in the number of older patients admitted with gastrointestinal (GI) disease and a 212% increase in the incidence of bowel obstruction from 1976 to 1989. Several studies have similarly reported a growing number of aged consumers of emergency care and call for research into the treatment of the elderly in the ED as well as the inclusion of this information into
OBSTRUCTION
Obstruction of the large or small bowel is a major health problem for the elderly. Abdominal distention, tenderness, vomiting, and abnormal bowel sounds are not always evident.
In the older patient, the cause of large bowel obstruction is predominantly colon carcinoma, with diverticulitis and sigmoid volvulus as less common causes. The risk of intra-abdominal cancer is age dependent, doubling with every decade over 40 years of age. Patients with more extensive cancer growth present with obvious
Peptic Ulcer Disease
The history of peptic ulcer disease in the elderly is often atypical, and symptoms may be of very recent onset. Complications occur more frequently and are often the first sign of the disease. In 1987, Chiverton and Hunt13 found an increasing mortality rate in patients over 60 years old, especially in women, with mortality rates 100 times higher than in the young.13 A study of elderly nonsteroidal anti-inflammatory drug (NSAID) users found they were over four times more likely to die from
VASCULAR
Atherosclerosis of the celiac, superior mesenteric, and inferior mesenteric arteries is reported to affect up to 50% of patients over 45 years of age and is even more frequent in those patients with other vascular disease. It is a highly fatal disease in the geriatric age group with mortality rates over 80%. Emboli, thrombosis, and a low flow state (nonocclusive ischemia) are the most frequent causes. Acute mesenteric ischemia produces a picture of acute abdominal pain, vomiting, diarrhea,
UROGENITAL DISEASE
There is a high incidence of urinary tract infections in the elderly. The incidence of bacteriuria in men aged 65 to 70 years is 3%, and increases to 20% over the age of 70 years. For women the incidence is even higher reaching 23% to 50%57 over the age of 80 years. Acute urinary tract infection and pyelonephritis may present with fever and abdominal pain.
In patients with previous voiding symptoms such as obstructive or irritative bladder complaints, who present with severe abdominal pain, the
MISCELLANEOUS CAUSES OF ABDOMINAL PAIN
It is estimated that three out of four patients presenting to the ED with the complaint of abdominal pain have a nonsurgical origin of the pain.59
In patients greater than 85 years old, "atypical" presentation of myocardial infarction should be expected. The nonspecific symptoms of shortness of breath, syncope, and acute confusion were reported more often in the elderly.5 The Framingham study found that "atypical" myocardial infarction tended to be seen in women and the older patient.37 An
SUMMARY
Evaluation of the older patient presents a unique challenge to the emergency physician. The increased age of the population, a high incidence of comorbidity, general poverty of history and clinical signs in acute abdominal conditions, poor reliability of diagnostic procedures, and the variable presentations of diseases with significant morbidity and mortality summarize the problems to be encountered with the complaint of abdominal pain in the elderly. The correct diagnosis is often difficult to
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Address reprint requests to Tracy G. Sanson, MD, FACEP 812 Lorena Road Lutz, FL 33549
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